Current strategies for the management of inguinal hernia: What are the available approaches and the key considerations?

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Introduction

Few surgical diagnoses have the degree of impact on the worldwide healthcare system as that of the inguinal hernia. It is estimated that approximately 20 million inguinal hernia repairs are performed each year throughout the world, with as many as 700,000 of these performed in the United States alone.1, 2 The lifetime risk of developing a groin hernia is estimated at 27%-43% in men and 3%-6% in women,3 most of which will ultimately require repair.4 Operation to repair inguinal hernias are often successful initially, but have historically been plagued by complications including (but not limited to) recurrence and chronic groin pain, with considerable variation as to the reported incidences of both.5 Obviously, it is of great interest when possible for surgeons to define best practices that allow durable inguinal hernia repairs that are cost effective and are associated with minimal morbidity. This continues to be a challenge since the current treatment of inguinal hernia is not standardized, despite the publication of several well-researched guidelines manuscripts.5

To fully understand the scope of this monograph, some historical context is necessary. The first inguinal hernia repairs were performed in the 1500s. These were tissue-based repairs involving resection of the hernia sac and simple reapproximation of the muscular and fascial components surrounding the defect.5 At the time, surgeons had little understanding of the complex anatomical relationships of the tissue planes they were working within, but this changed in the early 1800s with the work of Dr. Astley Cooper, whose elegant work on the subject of inguinal anatomy and inguinal hernia was instantly regarded as a seminal contribution to the medical literature.6 Further work followed by giants such as Franz Hesselbach, Antonio Scarpa, and Jules Cloquet who collectively, along with Cooper, provided the surgical community with the understanding of inguinal anatomy and function that to this day provides the basis for modern inguinal hernia repair techniques. The significance of their work and its place in surgical history are further evidenced by the eponyms that bear their names within the inguinal anatomy, many of which are perhaps the most well-known eponyms in use in surgery worldwide.6

The better understanding of the inguinal anatomy provided by the anatomical studies by Cooper and colleagues paved the way for the subsequent tissue repair techniques that followed. The most common of these were the Bassini, Shouldice, and McVay repairs. A discussion of the nuances of the different tissue repairs is beyond the scope of this chapter, but for the reader's perspective we will offer a few generalizations. This typically involved reapproximation of the layers of the inguinal canal to the shelving edge of the inguinal ligament, either en masse (Bassini) or as individual layers (Shouldice). The McVay repair is similar to that of the Bsssini except that the first few sutures were placed between the conjoined tendon/transversus abdominis arch and the Cooper (pectineal) ligament, transitioning to the inguinal ligament at the point that the femoral vein was encountered.7 Although the Shouldice repair is the most extensively studied and has yielded the best outcomes of the open repairs, the underlying theme of these repairs is that they involved reapproximating structures that were anatomically never together before so, by definition, they were all performed under tension. This led to unacceptably high recurrence rates with tissue repairs and to the widespread use of synthetic prosthetic mesh materials to avoid tension and support the repair.5 Of note, a tension-free tissue repair – the Desarda repair – has been developed. In the Desarda repair, the external oblique is transposed under the spermatic cord to cover the inguinal floor and then incised and sutured to the conjoined tendon, thereby forming an autogenous bridging patch.8 Although this repair is interesting and has yielded promising results in small studies, it lacks the long-term follow-up to endorse it as a viable alternative at this time. In fact, recent guidelines support only the Shouldice repair as the standard against which tissue-based repairs should be measured.5

Synthetic mesh was first developed in the 1950s, and was at that time suggested to be used only in patients with large or recurrent defects that were felt to carry a higher risk of recurrence and typically placed over a Bassini repair as a means of reinforcement. However, it was the routine use of polypropylene mesh placed in a tension-free manner that was perhaps the biggest innovation in hernia surgery since the famous anatomical treatises of Cooper. This technique, described in 1986, involved the placement of a sheet of polypropylene mesh over the inguinal floor with no attempt at reapproximation of the conjoined tendon to the inguinal ligament, followed by immediate ambulation and early return to normal activities as tolerated. Perhaps the most significant advantage of the Lichtenstein repair was the reproducibility of its excellent results by other surgeons – a phenomenon that had been unobtainable with the Shouldice repair.9 Since then, a variety of open mesh-based tension-free repairs have emerged. These have included the “plug and patch” repair, bilayer polypropylene repair (Gilbert), and open preperitoneal approaches (transinguinal and transrectus). In recently released guidelines however, the Lichtenstein remains by consensus the “gold standard” open mesh repair, the most extensively studied, and the repair by which other open repairs are judged.5

Laparoendoscopic repair of inguinal hernia, in which the hernia sac is dissected free from the spermatic cord and the entire myopectineal orifice is covered with prosthetic mesh may be performed either laparoscopically (transabdominal preperitoneal (TAPP) or totally extraperitoneal preperitoneal (TEP), or robotically TAPP (rTAPP). The utilization of laparo-endoscopic techniques ranges from 55% in highly resourced countries to 0% in areas where resources are more sparser.5 Although initial large scale randomized trials suggested that the laparo-endoscopic approach was inferior, subsequent analysis of these studies have suggested that success is more dependent on the skill of the operating surgeon – more specifically the number of cases he or she has performed to acquire the necessary proficiency to achieve excellent results with these techniques.10 In any case, subsequent studies have indicated acceptable recurrence rates as well as perhaps lower rates of acute and chronic pain with the laparo-endoscopic technique. In addition, the ability to exclude and treat a femoral defect without extending the scope of the operation is another theoretical advantage.5 Whether or not technical advantages provided by robotic-wristed instruments and the lack of need for the use of expensive disposable dissecting balloons in performing a rTAPP provide any advantage to the robotic approach over conventional laparoscopy is another actively debated issue. All of these issues are explored more thoroughly in subsequent sections of the chapter.

As one can tell, the choices for the repair are many and varied, and this fact suggests that a “one size fits all best method” does not exist. Rather, one should view all of the different approaches as additional tools to add to one's armamentarium. So then, how does one choose which repair to employ and when? In the context of inguinal hernia repair we believe that there are several key considerations for the surgeon in choosing which approach to employ. However, before discussing these considerations one important point must be stressed. All of the recommendations made in the subsequent section must be considered within the context of the skill and experience of the individual surgeon and his or her level of experience with a given approach. Subsequently, the approach to each individual patient and their hernia must be tailored accordingly with safety and avoidance of operative and postoperative morbidity as a primary goal. Too often we have seen patients injured when a new technique is performed by a surgeon without adequate training or expertise in that particular procedure. Remember, primum non nocere. First, do no harm.

It is our goal to critically evaluate, compare and contrast the 3 major categories of inguinal hernia repair techniques: open, laparoscopic (both TAPP and TEP), and robotic (rTAPP). To do this effectively and objectively, we have identified 5 key areas for consideration by the surgeon in choosing his or her operative approach. Each has been given its own section later in the monograph. These include:

Recurrences after inguinal hernia are troublesome and costly. Traditionally, recurrence rates have been used as perhaps the most important benchmark when assessing the adequacy of an inguinal hernia repair. Presuming that the repairs are properly performed, are there substantial differences in recurrence rates between the open, laparoscopic, and robotic approaches? If so, which repairs are the most and least favorable, and how do we as surgeons integrate this information into an evidence-based choice?

Both acute and chronic pain after inguinal hernia repair have emerged as major considerations for the practicing surgeon today. Reducing acute pain may facilitate an earlier return to normal activities, including work, and is associated with greater overall patient satisfaction. Chronic pain represents a significant challenge for the clinician. It is thought to occur in 1%-12% of patients, with an overall incidence of debilitating pain from 0.5% to 6%.5 The treatment of chronic groin pain after hernia repair represents a significant challenge, so prevention of this condition is a topic of major interest. In this section differences in the magnitude and incidence of both acute and chronic pain with the different approaches are discussed. In addition, factors predisposing to chronic pain as well as strategies for the prevention and treatment of chronic pain are presented.

Is one approach clearly advantageous over another in terms of cost to the healthcare system? Initial criticisms of laparo-endoscopic approaches focused heavily on this issue, touting higher procedural costs associated with an endoscopic approach when compared with an open approach. This has been challenged in recent years, but it remains a significant point of debate when comparing the 2 approaches, and the addition of robotic inguinal hernia repair has only served to further fuel the debate.

As mentioned previously, the learning curve has been linked to differences in outcomes in inguinal hernia repair, especially in laparoscopic repairs.10 How much is this a factor today, especially as more and more surgeons are obtaining experience with laparoscopic and robotic technologies in their residencies and fellowships? How many cases are adequate to perform laparoscopic or robotic procedures proficiently, and how can proficiency be assessed objectively and consistently? Also, in a world where the paradigm for repair may be shifting more toward the laparoscopic approach, is it possible that the proficiency of surgeons in open repairs will suffer, much as the proficiency with tissue repairs has suffered as mesh-based repairs have become the standard in adult inguinal hernia repairs? All of these are reasonable and pertinent questions.

Current expert opinion states that there is likely no single “best approach” to the treatment of inguinal hernia.5 Rather, each approach should be viewed as a tool for the hernia surgeon's toolbox and should be used when clinical circumstances dictate. Simply put, are there cases – for example the acutely incarcerated hernia or the giant inguinoscrotal hernia, for example – that should be treated with one particular approach in most cases? In this section, specific clinical scenarios are discussed, with an emphasis on which procedural characteristics may provide an advantage leading to a superior result if used in a given particular clinical scenario.

Hernia surgery is currently undergoing a renaissance period in the United States and worldwide with the advent of better evidence-based clinical guidelines,5 a greater understanding of the hernia patient and the specific challenges associated with this unique disease process, higher quality published outcomes data, and more elegant techniques for repair. Indeed, it is an exciting time to be a hernia surgeon. We hope that the following sections help to advance the reader's knowledge and understanding of this ever-evolving field of surgery.

Section snippets

Consideration of recurrence rates

With an estimated 20 million cases performed around the world annually, the inguinal hernia repair is a procedure known and often practiced by the general surgeon.3 As with any operative procedure, the ultimate measure of success is often reflected in the outcomes. Here, we discuss one of the most important benchmarks of a successful hernia repair: a consideration of the recurrence rates of the various repair methods. In this section, we review the recurrence rates of the most common and

Considerations regarding pain – Both acute and chronic

Pain after groin hernia repair remains a topic of great interest to surgeons and patients. The problem of chronic groin pain is a significant one and one that is likely underreported in the hernia literature. The incidence of chronic groin pain is estimated to be approximately 10%-12%, with the incidence of debilitating chronic symptoms present in 0.5%-6% of patients.5 The specific definition of chronic groin pain is pain lasting longer than 3 months after hernia repair, and its incidence has

Cost considerations

Healthcare costs in the United States comprise 17.9% of gross domestic product in 2017, while overall health lags behind other developed nations. Contributors to these high costs include the cost of labor, goods, and administrative costs.56 These healthcare costs continue to escalate, with healthcare spending projected to continue to outpace inflation.57 In order to stem the tide of rising healthcare costs, providing cost-effective treatment is imperative.

Inguinal hernia repair is one of the

Considerations relating to the learning curve of the various repairs

Inguinal hernia repair remains one of the most common procedures performed by the general surgeon and accounts for nearly 75% of all hernias, with nearly 20 million repairs annually.17 The most commonly utilized techniques for inguinal hernia repair in the United States include the Lichtenstein repair followed by laparoscopic repairs (TAPP and TEP) and, more recently, robotically assisted laparoendoscopic repairs (rTAPP). Laparoscopic repairs may be performed through a totally extraperitoneal

Consideration of special circumstances: Are there any specific clinical circumstances which favor one approach over another?

All hernia repairs should be performed in the safest and most effective way utilizing the technical skills and resources available to each individual surgeon. Each technique has a learning curve that must be worked through to allow equivalent outcomes. Once this is achieved the well-rounded hernia surgeon is then armed with all of the state-of-the-art approaches to the task of inguinal hernia repair. In this situation, the choice of repair may still be affected by surgeon or patient preference,

Conclusions

In the last few years inguinal hernia repair has experienced a renaissance period, with the result being an expanded range of available options for repair under various clinical circumstances. The data reviewed in this monograph demonstrate that there is no “one size fits all” approach, and that what may be the right repair for one patient may not be the best choice for another patient. All of the considerations-recurrence rates, costs both initial and downstream, experience and learning curve,

Acknowledgments

The authors would like to acknowledge Dr. Gina Adrales, Dr. William Hope, Dr. Archana Ramaswamy, and Dr. Benjamin Poulose, all of whom participated with Drs. Richmond and Roth in a session addressing this topic at the 2018 American College of Surgeons Clinical Congress held on October 24, 2018 in Boston, Massachusetts. It was the success of this session that provided the impetus for this manuscript.

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